Elizabeth Dzeng2015-03-31T14:40:48-04:00Elizabeth Dzenghttp://www.huffingtonpost.co.uk/author/index.php?author=liz-dzengCopyright 2008, HuffingtonPost.com, Inc.HuffingtonPost Blogger Feed for Elizabeth DzengGood old fashioned elbow grease.The Double Helical Structure of DNA: Scientific Canon Today, but Iconoclastic at the Timetag:www.huffingtonpost.com,2014:/theblog//3.48740542014-02-28T10:07:59-05:002014-04-30T05:59:02-04:00Elizabeth Dzenghttp://www.huffingtonpost.com/liz-dzeng/
I recently had the privilege of speaking with Professor Sydney Brenner, Nobel Laureate in Physiology or Medicine, who worked closely with Watson and Crick at Cambridge's Medical Research Council's (MRC) Laboratory for Molecular Biology (LMB) on their quest to unlock the genetic code.

The 1950s to 1960s at the LMB was a renaissance of biological discovery, when a group of young, intrepid scientists made fundamental advances that overturned conventional thinking. An extraordinary number of successive innovations elucidated our understanding of the genetic code, the process by which cells in our body translate information stored in our DNA into proteins, vital molecules important to the structure and functioning of cells.

It was here that Watson and Crick discovered the double-helical structure of DNA. Brenner was one of the first scientists to see this ground-breaking model, driving from Oxford, where he was working at the time in the Department of Chemistry, to Cambridge to witness this breakthrough.

This young group of scientists, considered renegades at the time, made a series of successive revolutionary discoveries that ultimately led to the creation of a new field called molecular biology. This new information ushered in a new era of biological science and has formed the basis of nearly all subsequent discoveries in the field, from understanding the mechanisms of diseases, to the development of new drugs for diseases such as cancer.

Imagining the creative energy that drove these discoveries was truly inspirational, and so, I asked Professor Brenner what it felt like to be part of this scientific adventure.

Sydney Brenner: I think it's really hard to communicate that because I lived through the entire period from its very beginning, and it took on different forms as matters progressed. So it was, of course, wonderful. That's what I tell students. The way to succeed is to get born at the right time and in the right place. If you can do that then you are bound to succeed. You have to be receptive and have some talent as well.

To have seen the development of a subject, which was looked upon with disdain by the establishment from the very start, actually become the basis of our whole approach to biology today. That is something that was worth living for.

I remember Francis Crick gave a lecture in 1958, in which he discussed the adapter hypothesis at the time. He proposed that there were twenty enzymes, which linked amino acids to twenty different molecules of RNA, which we call adapters. It was these adapters that lined up the amino acids. The adapter hypothesis was conceived I think as early as 1954 and of course it was to explain these two languages: DNA, the language of information, and proteins, the language of work.

Of course that was a paradox, because how did you get one without the other? That was solved by discovering that a molecule from RNA could actually have function. So this information on RNA, which happened much later really, solved that problem as far as origins were concerned.

(Professor Brenner was far too modest here, as it was he who discovered RNA's critical role in this translation from gene to protein.)

So he [Crick] gave the lecture and biochemists stood up in the audience and said this is completely ridiculous, because if there were twenty enzymes, we biochemists would have already discovered them. To them, the fact that they still hadn't went to show that this was nonsense. Little did the man know that at that very moment scientists were in the process of finding the very first of these enzymes, which today we know are the enzymes that combined amino acids with transfer RNA. And so you really had to say that the message kept its purity all the way through.

What people don't realise is that at the beginning, it was just a handful of people who saw the light, if I can put it that way. So it was like belonging to an evangelical sect, because there were so few of us, and all the others sort of thought that there was something wrong with us. But once you saw the light you were just certain that you had to be right, that it was the right way to do it and the right answer. And of course our faith, if you like, has been borne out.

They weren't willing to believe. Of course they just said, well, what you're trying to do is impossible. That's what they said about crystallography of large molecules. They just said it's hopeless. It's a hopeless task. And so what we were trying to do with the chemistry of proteins and nucleic acids looked hopeless for a long time. Partly because they didn't understand how they were built, which I think we molecular biologists had the first insight into, and partly because they just thought they were amorphous blobs and would never be able to be analysed.

I remember when going to London to talk at meetings, people used to ask me what am I going to do in London, and I used to tell them I'm going to preach to the heathens. We viewed most of everybody else as not doing the right science. Like one says, the young Turks will become old Greeks. That's the trouble with life. I think molecular biology was marvellous because every time you thought it was over and it was just going to be boring, something new happened. It was happening every day.

So I don't know if you can ride on the crest of a wave; you can ride on it, I believe, forever. I think that being in science is the most incredible experience to have, and I now spend quite a lot of my time trying to help the younger people in science to enjoy it and not to feel that they are part of some gigantic machine, which a lot of people feel today.]]>Bringing Emotions Back Into Medicinetag:www.huffingtonpost.com,2013:/theblog//3.42050352013-11-02T16:35:59-04:002014-01-23T18:58:21-05:00Elizabeth Dzenghttp://www.huffingtonpost.com/liz-dzeng/
This perception is so exalted in medicine, that it was the motto of my medical school's residency program: Aequaminitas. Based on an essay of that title by Sir William Osler, it means unperturbability. They urged us to become that ideal doctor who had that, "coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness." It was these doctors who had the expertise to heal their patients, not ones who were so "weak" as to weep with a patient during life and death situations.

My last day of residency was my most memorable. I was rotating on the intensive care unit where a 21-year-old Mexican immigrant boy was dying of end stage testicular cancer that had spread throughout his body. His stomach was swollen from liver failure, he was in a deep coma from insults to his brain, and infection had spread throughout his blood and body. For days, we struggled to keep him alive -- tethered to life support, with virtually every organ maintained through artificial means. He was the sole breadwinner of his large family, and they were completely unprepared to let him go. His mother threatened to kill herself if her son died, and his brother begged to me every day to let him donate half his liver to his sibling.

He died during rounds on my last day. Seared into my mind was the image of his mother throwing herself onto the floor and hitting her hands and head on the floor, howling with sorrow. His father swept their daughter into his arms and ran out of the ICU with unbridled angst.

Every doctor in the room stood there watching in silence. I tried with all my might to control my tears. Blinking frequently. Thinking about hard medical facts. Staring at the ceiling. But it was not possible, so I quickly excused myself to run into the supply closet to weep in private. When I returned, rounds went on as if nothing had happened.

A recently essay by David Bornstein, "Medicine's Search for Meaning" resonated tremendously and brought these memories back to the fore. In it, he describes the need for a culture change within medicine to embrace emotions and provide compassionate care. His article and others have noted how a lack of humanism in medicine contributes to burnout and low physician satisfaction. Disillusioned physicians who initially pursued medical careers to connect with and help people, instead find themselves in a health care infrastructure dominated by bureaucracy and little time for patient interactions.

In order for programs such as the Healer's Art, to counter the dehumanizing aspects of medicine in a physician's professional life course, they must consider expanding to residency. Residency is the time when young doctors experience for the first time that terrifying sense of responsibility for making life and death decisions in the middle of the night, and having to tell a parent that their child has died.

These unforgettable experiences are watershed events in a doctor's life, as they are the moments where their actions directly impact patients, rather than in medical school where they are chiefly the apprentice watching it being done. I had taken the Healer's Art in medical school, but by the time residency rolled around there was little opportunity to circle back and reflect upon those lessons.

There is little time and space in the harried life of an intern to think about these sorts of things. Non-clinical time is packed with curricular essentials on the fundamentals of medicine. Yes, it is critical that a doctor understand how to treat high blood pressure and manage liver failure. But as the article stated, it is arguably as important to the therapeutic relationship to cultivate caring doctors who not only feel compassion, but also feel comfortable expressing it.

Perhaps more importantly, creating no-judgment spaces for dialogue amongst residents allows for mutual understandings of common experiences, which in my experience was completely alien in residency. I had always felt like there was something wrong with me for feeling emotions. I felt like everyone around me had a confidence and assurance that I never had, and did not experience the self-doubt I did when patients did poorly. Only upon reading Bornstein's article did I realize that I might not be alone.

This blog was originally published on KevinMD.com on 28 October, 2013]]>Fingerprints Point to the Future of Healthcaretag:www.huffingtonpost.com,2013:/theblog//3.41421162013-10-28T07:21:44-04:002013-12-28T05:12:01-05:00Elizabeth Dzenghttp://www.huffingtonpost.com/liz-dzeng/Written by Elizabeth Dzeng, Toby Norman, and Daniel Storisteanu

Health workers in developing countries face challenges that are often taken for granted in the developed world, but new technologies have the potential to become leap frog solutions that address such barriers. Major obstacles exist today in the identification of patients, a fundamental issue at the very core of delivery of health care in resource poor settings. All too often patients have medical histories that doctors or community health workers (CHW) have no access to. Addressing this difficulty would potentially revolutionize prevention and treatment in a diverse array of public health areas ranging from vaccination campaigns, to prenatal care, to improving treatment adherence in diseases such as tuberculosis and HIV.

Despite this, there has been limited innovation in this area. Most health systems in developing countries depend on paper records, which are easily lost and not immediately accessible. These records also assume a western notion of identification that fail to adapt to cultural variations such as multiple members of a community having the same name, and rural villagers often not knowing their exact date of birth. Compound this with inconsistent access to health care across wide geographical expanses, and it becomes extremely difficult to guarantee that a health worker will be able to identify the needs of her patient during an encounter.

Let's take the example of childhood vaccinations, one of the most cost effective interventions in public health. One child dies every twenty seconds from a vaccine preventable disease and almost one third of child deaths can be prevented through vaccinations. But the vulnerabilities of paper records make it challenging for CHWs to identify what immunizations a child has already had and which ones they needs during their visit.

In part due to these difficulties, we have only achieved approximately 80% coverage world wide using existing technologies and health systems. A recent study estimated that a scale up of five immunizations in 72 of the world's poorest countries could save 6.4 million children annually. We have started a social enterprise start up called SimPrints, which has the potential to contribute towards solving this global health challenge, as well as many others.

SimPrints is in the process of developing a mobile-based fingerprint scanner that instantly connects an individual's fingerprint to health records such as immunization records and prenatal visits. This Bluetooth-enabled scanner, allows for real time access to health records, which enables CHWs to instantaneously access critical information necessary to provide care. In contrast to paper records sitting unhelpfully back in the clinic office, this technology would enable a CHW to swipe the mother's fingerprint and receive an instantaneous update of what vaccines they have received and what needs to be administered that day.

This versatile technology would be compatible with existing mHealth applications and platforms, allowing for seamless integration into pre-existing systems through an application programming interface (API). Many future opportunities exist for SimPrints to become a platform technology that works with other technologies such as rapid diagnostic testing and point of care lab testing, to address challenges in drug adherence, disease monitoring, and diagnosis.

Another exciting arena for SimPrints are its potential applications in areas beyond public health. For example, mobile biometrics can address the challenge of tracking refugees and internally displaced persons (IDP). Identifying refugees is a significant challenge since many refugees lack formal identification and may have crossed several national borders. In these settings biometrics offer a powerful tool for aid workers to link refugees to a single unique identification that can connect GPS location, medical data, and aid records. This fingerprint identification would transcend time and geography to allow aid workers to adequately supply the camp and facilitate reunification of family members torn apart by war and conflict.

Dr. Alain Labrique, Director of the Johns Hopkins University Global mHealth Initiative recently challenged us with the notion that "identification is the holy grail of mHealth." We at SimPrints are excited to take on this issue and strive to substantively impact on-the-ground health care delivery through mobile biometrics.

This blog was originally posted on the Gates Foundation Impatient Optimist blog.]]>How Are Misaligned Incentives in Health Care Costing Tax Payers?tag:www.huffingtonpost.com,2013:/theblog//3.27153632013-02-19T06:11:04-05:002013-04-21T05:12:02-04:00Elizabeth Dzenghttp://www.huffingtonpost.com/liz-dzeng/
The social worker informed him that Medicare would not pay for home care nurse visits or supplies. BUT, Medicare would pay for inpatient rehabilitation, which he would be eligible for, just to receive these antibiotics. Given the choice of paying $7000 for home administration versus $0 for inpatient rehabilitation, naturally he chose inpatient rehabilitation.

The problem is, is that his inpatient stay would cost taxpayers approximately $21,000 - $350 for room and board plus additional costs for antibiotics and supplies, totaling approximately $500 a day. Furthermore, although he was well enough to be discharged home before Christmas, he needed to stay until he could be placed in rehab. Because of holiday scheduling, most rehabilitation facilities were not accepting admissions. Thus, he had to stay in the hospital an extra four days in the hospital over the weekend and holidays. Given that the average cost of a hospital stay is $2338 in Maryland, an additional $9352 or so was wasted on unnecessary expenses.

In sum, because financial incentives encouraged my patient to spend $0 rather than $7000 out of pocket, Medicare spent an unnecessary added $30,000 on his hospitalization and care.

To make matters worse, my patient didn't even want to go to rehab. He preferred to administer the antibiotics himself at home and found it hugely inconvenience to have to be an inpatient for six weeks just for antibiotics. He was a small business owner, and these extra days in rehabilitation would hinder his productivity at work. He was upset that he had to stay in the hospital over the holidays for unnecessary reasons. He was upset about this twisted logic, which forced him to choose the less resource efficient option and lamented the financial burden he was unwillingly imposing on taxpayers.

This decision would harm my patient in other ways. Medicare limits beneficiaries to sixty lifetime days of inpatient rehabilitation care. If he ever needed future inpatient care, he would have fewer days available to him. Staying in a hospital facility can also be harmful medically, as added days in the health care setting place him at an increased risk for health care acquired infections.

The United States has been in recession for years and calls for fiscal responsibility ring loudly. Fiscal crises and congressional deadlock have almost become the new normal. Rising health care costs account for 25% of total federal spending and stands at $2.8 trillion a year. This contributes a significant portion of our national debt at a time when we can't afford wasteful spending.

The Affordable Care Act has attempted to curtail waste through various mechanisms including redirecting care from high cost specialists to lower cost primary care doctors, restructuring reimbursement from fee for service to a value based model. Others have suggested various cost cutting mechanisms such as reducing overtreatment, implement market-based incentives, and reduce overhead.

My patient's situation illustrates another aspect of cost control that has not frequently been discussed. Skewed financial incentives caused by illogical Medical reimbursement schemes create additional unnecessary costs that are not just wasteful, but also harmful and inconvenient to patients. $30,000 is a great deal of money to waste on something that is medically unnecessary and unwanted.

This is but one example where misaligned incentives drive providers and patients to choose the less efficient, more wasteful option. Examples are abound in health care. My patients in New York regularly told me that they called an ambulance because it was cheaper to them (free!) than a $20 cab ride. An ambulance ride in New York City costs $704 per ride not including mileage. Medicare and Medicaid contribute approximately half of the FDNY's total revenue of $205 million yearly.

I remember referring one of my clinic patients to the social worker because she had recovered from depression and wanted to get a job. The social worker discouraged her from finding employment and instead advised her to volunteer because she would lose her disability benefits if she found gainful employment.

Because uninsured patients do not have outpatient drug coverage, it is not uncommon for uninsured cancer patients to be admitted to the hospital in order to get outpatient chemotherapy infusions. This adds approximately $2338, the average cost of an overnight admission, on top of what would have been an outpatient infusion.

I could go on and on.

Policy changes that systematically reform these misaligned incentives could do much to reduce illogical decisions that cause wasteful healthcare spending. Lobbying and patchwork legislation have led to our current system of fragmented reimbursement schemes where benefits initially meant to help patients, create unintended consequences leading to wasteful spending. Long-term solutions to counteract our increasing federal deficit require bending the cost curve of health care. Taking a careful look at Medicare reimbursements that don't make sense could potentially save millions of health care dollars and improve quality of care.

Special thanks to Donald List, LCSW-C, for helping me obtaining costs for the therapies and services mentioned in this article. ]]>The Hippocratic Paradox: When Is Resuscitating a Patient Doing Them Harm?tag:www.huffingtonpost.com,2013:/theblog//3.24791132013-01-17T19:00:00-05:002013-03-19T05:12:01-04:00Elizabeth Dzenghttp://www.huffingtonpost.com/liz-dzeng/
She had advanced stage throat cancer. Her tumor, on the left side of her neck, was both pushing into her airway and a major artery. As the tumor grew, the woman could no longer breathe, and when her artery ruptured, blood started pouring into her lungs.

She would die by drowning in her own blood.

Her husband was understandably overwhelmed and distraught. He instructed us to take any measures possible to keep her alive. She was too weak to contradict her impassioned and dedicated husband.

This was, in my view, the wrong choice from an ethical and clinical perspective. How could I uphold my oath to do no harm when I knew she would die a particularly gruesome death, and I was instructed by her husband to keep her alive and in this state? I would have to crack her ribs during chest compressions and electrocute her to attempt to restart her heart. Regardless of whether we could keep her heart beating, the rest of her body would still be irreparably consumed by cancer. It was anguishing to be forced to inflict this sort of violence on this dying woman.

Recently in the UK, a patient's family took doctors to court claiming that doctors at the Addenbrookes Hospital 'badgered' Janet Tracey, a 63-year-old woman into agreeing to a Do-Not-Resuscitate (DNR) order and ultimately instituted it without the family's permission. She had fractured her neck in a car accident shortly after she was diagnosed with terminal lung cancer. The controversy surrounding the incident spotlights questions of whether there is a legal duty to inform and consult patients on DNR decisions, and whether patients should have the right to demand resuscitation.

The courts decided the case should not go forward to judicial review, thus reaffirming that the decision to pursue CPR should be based on the doctor's clinical assessment of what is in the best interest of the patient. I believe that it was the right decision. CPR is not always the life saving procedure that one typically sees on television. Outcomes in patients who are in the last stages of a terminal illness are extremely poor and prolonged oxygen deprivation during CPR frequently results in irreversible neurological damage.

The debates surrounding this case reflect a rightful demand for greater control in personal health care decisions and enhanced communication between the provider and the patient. But, as was the case with the woman in New York, I have seen countless situations in America where physicians are put in the ethically uncomfortable position of having to aggressively intervene upon a patient they believe have no chance of survival.

In the US, any decision to institute a DNR order must come from the patient, his family, or appointed surrogate. While this gives families a sense of control and decision making capacity over their loved one's care, it also places a significant burden of guilt onto them. They are forced to make decisions that aren't actually choices. I found it cruel to have to ask families already suffering emotional trauma to 'refuse' this useless procedure. Not only does it create false hope, but it also makes families feel as if they're having to decide whether to give up on their loved one. When the end of life is inevitable, it is God or nature who decides, not doctors or families.

An essay by Ken Murray, an American physician, entitled 'How Doctors Die', resonated deeply amongst the American medical profession. He recognized that when it comes to themselves, most doctors do not want to be subjected to "futile" care. They know modern medicine's limits and its ability to subject our loved ones to "misery we would not inflict on a terrorist." Medical decisions to withhold CPR do not occur because doctors have given up, but instead from efforts to prevent unnecessary suffering at the end of life.

Unlike the US, here in the UK the ultimate decision regarding resuscitation lies with the doctor. The UK General Medical Council stipulates that doctors are not obligated to provide treatments at the end of life, including resuscitation, that would not be clinically appropriate or of overall benefit. This guidance reflects the position that these are clinical decisions; patients may not demand treatments that physicians believe would be futile or would not result in a meaningful prolongation of life.

The recent focus on autonomy over decisions at the end of life in the UK, through Tracey's court case as well as controversy over the Liverpool Care Pathway, highlight the need for continued dialogue and clarity on these issues. The lawyers involved in the Tracey case have rightly affirmed that these decisions should not be made in the courts - a process that encourages suspicion and public anxiety.

Instead, we should work together to foster trust and confidence in the health care system, by encouraging conversations about resuscitation decisions at all levels. The NHS's Dying Matters initiative has already pioneered efforts to change public perceptions of dying and counter unrealistic expectations. Future guidelines should be established through public consensus between practitioners who have professional expertise in this area and key stakeholders.

I feel that the UK is at a crossroads in much the same way that the US was several decades ago. High profile court cases surrounding patient rights at the end of life catalyzed a set of changes, which led to America's current system of aggressive treatments at all costs regardless of futility or clinical common sense. I encourage my British colleagues to looking across the pond to the US as a cautionary tale of how these decisions impact our ability to serve in the best interest of our patients.]]>